Documentation And Communication : Home Health And Hospice Agencies

The electronic medical record system (EMR) serves many purposes in an emergency for the patient, physicians, and hospitals involved in the diagnosis and care during an emergency.

The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.

For healthcare facilities, patient documentation is at the heart of providing quality care and maintaining financial integrity. With the trend in consolidation, unifying documentation between the inpatient and outpatient environment becomes a challenge. As IDNs acquire physician group practices, administrators struggle to get the disparate pieces aligned. Documentation needs to be standardized, compliant and controlled. In a post (Jayne, 2014) on HISTalk, a popular anonymous healthcare industry blog, Dr. Jayne detailed the distinct differences in workflows and habits — not to mention serious operational problems — her employer encountered when bringing on new physicians groups.

Nurses in bedside care spend most their time with the patient. Nurses collect and communicate data about the patient through information sources for the benefit of the other health care professionals who depend on the information to deliver care (Kelley, 2012). Nurse workflow and the quality of nursing care delivery may improve with the adoption EHR System to increase the ease and accessibility of information to provide time for nurses to analyze, synthesize, decide, and deliver patient care (Cornell, Riordan, et al., 2010).

Electronic Health Record, (EHR) electronic health records contain a person health record of a patient’s medical information that has been collected over time from previous visits to the physicians’ offices for medical reasons.

Electronic health record and electronic medical record (EMR) are often used interchangeably within the health care industry, but they actually mean different things in the regulatory arena. An EHR refers to an aggregate of a patient’s EMR data that is generated over time by various institutions and can be shared among them. An institution can use EHR technology only if it has an EMR system that is capable of interoperating with other EMR systems.

Hospice Home Health is a sub organization of the Trinity Health Hospital, which is comprised of emergency, specialty services, as well as therapy and rehabilitation for Minot, North Dakota and its surrounding areas (Trinity Health, 2015). Trinity Health’s is committed to the continuous improvement of quality, the employees, medical staff, board of directors and volunteers of Trinity Health uphold the following values of integrity, accountability, passion, respect, and teamwork (Trinity Health, 2015). According to Trinity Hospital they will achieve and sustain excellence by; being futuristic and proactive in continuous performance improvement, exceeding professional quality standards and customer expectations, providing sensitivity in service

The electronic medical record (EMR) is basicly the patient’s medical record from an individual medical practice, hospital and or pharmacy. It does not go outside from the facility where it was created. Whereas an electronic health record (EHR) is the patient’s electronic medical record from multiple medical practices combined into one database. The electronic health record can be view outside from where it was originally created. The total practice management system is a software category that handles all the day-to-day operations of the medical practice.

An Electronic health record (EHR) is a longitudinal electronic health record of a patients information generated together by 1 or more encounters in all health care settings. Such information included in a patient file (EHR) are as such, the patient demographics, notes of patient vital signs, from each visit, medical history, laboratory results and other reports given from doctors, nurses and other physicians.

An electronic health record (EHR) basically refers to the systematized collection of the patient and the population electronically stores health information in a more organized and a digital format. The records can even be shared across the health care settings. The records are even shared through the network connected, enterprise wide information system or even with the other information networks.

An EMR contains the standard medical and clinical data gathered in one provider’s office. EHR go beyond the data collected in the provider’s office and include a more comprehensive patient history (Benefits of EHRs, n.d.).

The strengths of EHR is that all information of the patient’s medical history is kept electronically instead of paper. This can help save trees and have all information kept in virtual folders under the patient names. Doctors can easily read everything about a patient with just a click of a button or a tap on a screen. This means that doctors can work in a faster speed and not have to ask “why are you here today” when it is obviously on the screen. Instead, the doctors could go straight to asking, “what are you feeling and where is the pain?” Since doctors have sloppy hand writing, EHR can stop the misdiagnoses and cutting off patient’s limbs.

What is Electronic Health Records (EHR), computerized form of a patient’s medical chart. With electronic health records patient’s data is available at a click of a key to any authorized users. Medical staff are able to access medical and treatment histories of patients from a system which is designed to go beyond clinical data collection in any medical facility. Electronic health records contain a patient’s diagnosis, current and non-current medications, medical history, immunization dates, treatment plans, radiology in images, allergies and laboratory test results. Electronic health records allow physicians evidence based tools which are used to make decisions in regards to patients care or method of treatment.

The Electronic Health Records (EHR) includes the patient health information. For example, diagnoses, lab results, the patient medical history, process notes, patient demographics, vital signs, medications. Is entered in the EHR computer software at the provider's office. Its a patient health information system. Use to send information to other providers. It includes all personnel involved in patient care.

In order for one to understand the risks involved in the use of electronic medical records one needs to understand the meaning behind what it is. An electronic medical record (EMR) is a